Haryana

Ambala

CC/150/2011

RAM CHANDER - Complainant(s)

Versus

MAX NEW YORK LIFE INSS. - Opp.Party(s)

J.S.Bajwa

28 Nov 2016

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMBALA.

 

               Complaint Case No.    : 150 of 2011

   Date of Institution       : 11.05.2011

               Date of Decision         : 28.11.2016

 

 

Ram Chander Jassi R/o H.No.10, Ward No.11, Mata Gujri Marg, East Durga Nagar, Jalbera, District Ambala.

                                                                                               

                                                                                                                                       ……Complainant.

                                                                                                       Versus

 

1.        Max New York Life Insurance Co. Operation Centre, 2^nd Floor 90-A, ector-18, Udyog Vihar, Gurgaon. Registered Office Max House 3^rd Floor, 1 Dr. Jha Marg,Okhla New Delhi.

 

2.        Max New York Life Insurance Company SCO No.101-102-103 2^nd Floor, Batra Building, Sector 17-D, Chandigarh.

 

3.        Branch Office through Vinod Kumar of Max New York Life Insurance Co. Ltd., Shree Complex, Ist Floor Cross Road, 3-Punjabi Mohalla, Ambala Cantt.

 

                                                                                                ……Opposite Parties.

 

Complaint Under Section 12 of the Consumer Protection Act.

 

BEFORE:       SH. D.N. ARORA, PRESIDENT.

                        SH. PUSHPENDER KUMAR, MEMBER.

                       

Present:          Sh. J.S. Bajwa, Adv. for complainant.

                        Sh. Vishal Mittal, Adv. for Ops.

 

ORDER.

 

                        In nutshell, brief facts of the complaint are that the complainant got his wife Smt. Pushpa Jassi insured with OP No.1 vide policy No.717995419 dated 28.01.2009 for Rs.4.00 lacs and paid the amount through OP No.3. It has been submitted that  after getting  the said policy, wife of complainant felt pain  and was admitted in Silver Oaks Hospital, Mohali on 06.07.2009 where she remained admitted upto 28.07.2009 and doctors found pain in Hypochondrium.  She again remained admitted in the said hospital from 12.02.2010 to 20.02.2010.  It has been submitted that at the time of taking the policy, wife of complainant was hale and hearty and was  medically examined  by the authorized doctor of  the Ops and was not suffering from any diseases. It has been submitted that again wife of complainant felt some pain/problem and was admitted in Military Hospital, Ambala from 08.02.2010 to 10.02.2010 and lastly expired on 10.12.2010 in the said hospital. So, complainant approached the Ops for the payment of insurance claim but they did not pay any heed to his genuine requests, so a legal notice dated 25.03.2011 served upon the OPs but of no use.  Hence, the present complain seeking relief as per prayer clause.

2.                     Upon notice, Ops appeared through counsel and tendered reply raising preliminary objections qua maintainability of complaint, suppression of material facts and cause of action. On merits, it has been submitted that life assured after fully understanding all the terms & conditions of the policy applied for the said plan and the policy was issued accordingly.  It has been submitted that from record of Silver Oak Hospital, it is clear that the DLI was a known case of chronic renal failure since January 2009 with hypertension for 8-10 years and with Diabetes Melitus for 6-7 years  and the same was not disclosed  at the time of filing the proposal form and the policy was obtained by giving false information with a view to make unlawful gain  by defrauding the OP. It has been admitted that CAT 1 (Category 1) which is a general medical examination was conducted by the Op at the time of policy issuance and the policy was issued at standard rates.  It is submitted that CAT 1 is a general examination which is conducted on the basis of facts disclosed by the insured about his/her health but no specific test pertaining to hypertension, diabetes mellitus or kidney was conducted by them.  As such, the Op prayed for dismissal of the complaint.

3.                     To prove his version, complainant tendered his affidavit as Annexure CX  alongwith documents as Annexures C1 to C-16 and closed the evidence whereas on the other hand, Ops not bothered to adduce any evidence despite availing sufficient opportunities and the same was closed by court vide order dated 04.02.2015. 

4.                     We have heard learned counsel for the parties and gone through the case file very carefully.  Counsel for Ops has argued that at the time of filling of proposal form, deceased Pushpa Jassi (deceased life assured) did not disclose true facts about her pre-existing disease intentionally and made a false answer to the questions mentioned in the proposal form whereas she was a case of chronic renal failure since January 2009, with hypertension for 8-10 years and with Diabetes Mellitus for 6-7 years before taking the policy. Had she disclosed the said disease in the proposal form, the OP insurance company would not have issued the policy in question to the life assured. As such, she has played fraud upon the answering OPs.  Thus under the terms and conditions of the OP-company, if any information given by the assured person in the proposal form is found false or incorrect, in that event, the contract  become void ab-initio and nothing is payable to the insured person and the amount deposited by him/her shall be forfeited.  Hence, the OP is not entitled the any claim. 

                        On the other hand, Learned counsel for the complainant argued that claim of the complainant regarding death of his wife Pushpa Jassi who was insured with OP Insurance Company has wrongly & illegally  been not released by the OP on the ground that the deceased (life assured) was suffering pre-existing disease of Diabetes Mellitus etc. and thereby died. Counsel for the complainant further urged that  at the time of taking policy, the proposal form was filled by Agent of LIC and life assured has only signed the same whereas she had given all necessary information to him.

5.                     After going through the arguments of counsel for the parties,  the first and foremost question arises for consideration before us is “Whether the Deceased Life Assured-Pushpa Jassi was having any pre-existing deceased or not?

                        Onus to prove the abovesaid question was upon the OP but they did not adduce any evidence oral or documentary and the evidence was closed by court order dated 04.02.2015.  However, the Ops in their written statement has averred that the deceased (life assured) Smt. Pushpa Jassi was suffering pre-existing disease of Diabetes Mellitus etc. and thereby died.  We have gone through the documents placed on file by complainant viz. Repudiation Letter (Annexure C-1), Proposal Form/policy document (Annexure C-2), Attending Physicians Statement for Death Claim (Annexure C-3) and Payment receipt dated 04.10.2010 as Annexure C-11.  Perusal of document Annexure C-1 reveals that Op has repudiated the claim of complainant on the ground of ‘material medical non-disclosure of Chronic Renal Failure, Hypertension and Diabetes Mellitus by Mrs. Pushpa Jassi.’ Perusal of proposal form/policy document (Annexure C-2) reveals that life assured Smt. Pushpa Jassi was insured for an amount of Rs.4.00 lacs having installment of Rs.5000/- per quarter commencing from 14.01.2009 for a period of 20 years and installment payment receipt (Annexure C-11) shows that the last installment for the policy was paid on 04.10.2010 and complainant Ram Chand has been shown as nominee in the policy.  Admittedly DLI Smt. Phsupa Jassi died on 10.12.2010, meaning thereby that at the time of death of Smt. Pushpa Jassi, the policy was alive. Perusal of treatment record Annexures C-3, C-12 nowhere reveals that Smt. Pushpa Jassi was suffering from  any pre-existing disease. We have also gone through the medical certificate (Annexure C-13) issued by the treating doctor of the ECHS Polyclinic, Ambala clearly mentions that  diseased was under  treatment in Silver oaks hospital, Mohali since 06.07.2009 to 07.12.2010 but there is no document on the file that at the time of purchasing the policy complainant was taking any treatment  from the hospital prior to taking the policy. As such, the Op has wrongly repudiated the claim of the complainant vide repudiation letter (Annexure C-1) dated 18.02.2011 and the same is hereby set aside.  Accordingly, the complaint is allowed with no order as to costs and Ops No.1 & 2 are directed to comply with the following directions within thirty days of the receipt of copy of order:-

(i)        To pay a sum of Rs.4,00,000/- (sum assured as mentioned in Policy Document Annexure C-2) to the complainant being nominee of the life assured alongwith simple interest @ 9% per annum from the date of filing of complaint till its actual realization.

 

                        Copies of this order be sent to the parties concerned, free of costs.  File be consigned to the record room after due compliance. 

                                                                                                    Sd/-

Announced on:28.11.2016                                                 (D.N. ARORA)                                                                                                                                                                                                            PRESIDENT

                                                                                                                

                                                                                               Sd/-

                                                                        (PUSHPENDER KUMAR)                                                                                                                                                                                             MEMBER